Prehospital emergency medical services

Area of Science:

• Emergency medicine
• Medical ethics

Background:

• Prehospital Do-Not-Resuscitate (DNR) orders present ethical challenges for emergency medical technicians with defibrillation skills (EMT-Ds).
• A system without a prehospital DNR policy mandates resuscitation, creating conflict with patient wishes.

Purpose of the Study:

• To determine the frequency of EMT-Ds encountering prehospital DNR orders.
• To assess EMT-Ds' comfort levels when dealing with DNR orders.
• To describe prehospital care provided to patients with DNR orders in a mandatory resuscitation system.

Main Methods:

• A 13-item survey was developed using Dillman methodology and mailed to 764 EMT-Ds in metropolitan Toronto.
• Responses were analyzed using Likert scales, limited-option, and open-ended questions.
• Narrative responses were categorized, with inter-rater reliability assessed using kappa values.

Main Results:

• 58% of responding EMT-Ds "sometimes," "frequently," or "all the time" encountered patients with DNR orders.
• 11% honored DNR orders, and 27% provided basic resuscitation to comply with regulations.
• EMT-Ds cited patient/family concern, fear of repercussions, and personal ethics as reasons for their dilemma.
• 96% of EMT-Ds would be comfortable with written DNR orders, compared to 62% with verbal orders.

Conclusions:

• Prehospital DNR orders are common and often honored by EMT-Ds, indicating a disregard for current mandatory resuscitation regulations.
• EMT-Ds express greater comfort with written DNR orders over verbal ones.
• Development and implementation of an ethical prehospital DNR policy are recommended.